S0326 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull' TNG-ELECTRICAL PE uD. 0 3'6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L
BUILDING PR(1JECI'IDENTIFICATION
RUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
106 - LGrtaaj
I Kdi
NER'S N PHONE: CONTRACT/X12'3 NAME LIC NO:
�' SIC-G6Pe / NIC CONTRROL# w
ITECf.....INEER: IC NO: ADDRES : ID ) a.�
nn c9 0,6C yl�S "�{
CONTACT: //,�-�'�,� PHONE: �J BUILDING PERMIT INFO
N.kfA) �+Z7��77 • ❑ Consultant Fees Paid by Applicant(Initial) D E.i/ PLUMB Nil: it
�'-7N) 96"7-1078
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section 701 of Division 3 ofthe Business and Professions Code.and my license i.s RESIDENTIAL:
W O p PERMIT ISSUANCE
CWF in full force and effect. SP JWh C KITCHPLUMBING BE
QUU Locnxe Cl... LieN APPLIANCIA-BESIDES'I'IAI. HTION ❑PLUMI{ING Rii-PIPE
vFi<2 Da¢ Contrucmr
I.�to ARCHITECTS DECLARATION PANEL 5 MULTI-UNIT ❑STRUCTURAL
MODIFICATION
ZOZy Z 1 understand my plans shall be used as public records.
�G UPTO?IM)AMPS ERIOR ❑CHLMNGI"REPAIR
I-�2F"ad Licensed Pmtessional 201-JUMIAMPS IAfPROVEME, CSWIMMING POOLS
,J OWNER-BUILDER DECLARATION OVER IWMI AMPS ]BATH REMODELIREI'AIR ❑DEMOLITION
p�C W rm 6 1 hereby affithat 1 nm umvmpl frothe Counat or'v License Low far the
X 3 y O following rw,enn.(Section 7031.5,]business and Prefessio.x Codo
Cottle:Any city or CnmY SIGNS FLIiGTRIGAL ❑OTHER
ul LL H which requires a permit it)construct,alter,improve,demolish,or repair any aremre
I,< prior to it issuance.also rectums theapplicam for such permit to file a.signed statement SPECIAL CIRCUIT/MIS .
fly that he,,licensed pimameome pownt.m.fine Contmcnue,License tax'IChapmr9 Comm
F,RCIAL:
W (vommcnciagwith Section 7000)of Division3 ofthe Businessand Professions ClNelor TEMP.MET OR PoLEI .T.
d a C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEN' /ADDITION ❑DEMOLITION
Xn¢. Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
^m
Out me five hundred dollars(851X8. ❑TIiN 6 ��FOODSERVICE
'y SWIMMING POOL CLECPRIC IMPROVE IE {/ r/1
.F.SaO Q I,us owner of the nropeny,or my cntpinyacs with wages us their sole compensation. �C ER (/
Sap. wdl do the work.and theswaure is notmmnded oroBMdfor sale lSec.7019,Business QG(�I `f
W m and Pmfexsions Cale:The Contractors License taw does not apply to an Owner of OUTLET S-SWITCHES-FIXTURES lr
13 progeny who builds or improves thereon.and who does such work himself m ilmugh f SLI
his own employees,ptnvided that such improvementt are not intended cr offered fur NEW RISIDF,NTIAL ELECT S
sale.If.however the building or improcuncnt is sold within one year of completion,the
SQ.Ff.FL^(bR $ISQ.FT
er-builder will have the burden of proving that he did not build nr improve tar pn, O 1
POO,of side.) A ` 1`
Q 1,as owner it me progeny,.,it exclus vel,contracting with hreased contractor,it,
construct the project(Sec.70bf.Business and Professions Cooley The Coatracmr.s Li- -
nutawdtsexnm apply no an owner of pmpruy isho buadxtsr imprme,thereon.and QTY. - PLUMBING PERMIT FEE
who contracts forsuch projects with a contractors)licensed pursuant to the Colors x
License law. PERMIT ISSUANCE
Q 1 am exempt o def Sec. .B&P C for this reason
ALTER VALUATION
Goner ► 3
WORKER'S COMI'13N. 1 DECLARA'T'ION BACK PLIIW NROTECT.DEVICE
I hereby affiantmandsa penallyof of
neo wlfin%umor'othe hollowing declarations
have hrAb,ilimainaie,Certilcateof Conant to yell-insure for Workers Compen- DRAINS-Fl.00R.ROOF,AREA.GOND. - STORMS TYPE CONSTRUCTION
wahm.as provided for by Section 3700 of the labor Code.for the ped.mmnce.f the
FlXTURIS-PER TRAP
work for which this peit is issued.
wrm .
1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Tenor Cade,for the penininvnceofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.J OUTLET'S OCC GROUP APN
My Worked.C.ntpcnsntion Insurance varier and Policy nwnMr art:
Cartier. Policy No,: GAS-EA.SYffiTL'M-OVIiR d(HA)
/ C17RTIFICATE OF EXEMPTION FROM WORKERSGREASCf NDU$TRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEF.
(TLissection nerd not be compincd ifthe .it is forart,hundred dollars fS10(I) GREASETRAP
I'hANCHECK PEE
or less) r
I doily that in the perfmmuccofthe work For whichthim permit is issued,I shall SEW17H-SANI1 ARY-S'1'ORM EA.200 FT.
nor employ any peon^in any nwnuer ao as,,bovine,s.hjc,m the Workers'Condt
o- IiNL'RGY FEB
Z .,.an Luwlsal Calhbmia.Date WA7 LR IIEATF,R W/VF,N'HELECFR GRADING FEE
z 0 Applicant t
NOTICE TO APPLICANT:If,after making this Ccnificmv of F,xcmption,you should WATER SYSTEMOREAT'INC, SOILS FEE
7 become.object nt the Work,,,C.mpeasators provisions of the I,Mtr Code,you must
{kl forthwith comply with such provision,or this permit shall he deemed invoked. NATER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,II'. D u Receipt
I hereby^ffmn that'here is n umvtnmtlon lend)^g agency for be perbnntunee,It
{UH the work for which Otis lx—it is issued 13ce.3097.Civ.CJ TOTAL..
Lender's Name
S.
C^ GUk1 Lendds Address ItUILDIN FE
1 1 cenily thin I have moa this applicants.sad sate that he shoot,information is `
FrN
correct,I agree to comply with all city and county ordinances and state laws relatingm QTY MECHANICAL PERMIT FEE SIRSM FEB
U Z building construction,and hereby authnrire mpresemative.s of this city to enter O,onme
r above-mentioned property for inspection parpoxts. t PERMIT ISSUANCE 11d7JIRIG FEF,
(We)agmt to wave,indnnai ly mrd keep han ileo the City of Conemm"aEnind
Iiabilities,juJgnenlx,usms and expcnus wbielunxy in any way accrue aEains suit City ALT&illlt ADDTOMECH. I'.IJMBINGFIT.
to nsequence of rhe gmming of this peroral.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.111X1 CFM) MI: ANICALVEH
SOURC` 11
EGUL)TIONS. z� /
/ }((UL _ AIR HANDLING UNIT(OVER .1100 CFNf) CONST' iCIION TAX
/� <�
Sigrawre of ApplmvnllCommcmr Dm4 E%IIAUST IIOOD(W/DUCD IIOl151NG TICATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will lhtappliricamfmurc builiingxcupant vara or hvndlelia-uhim,material HIiATINO UNIT(TO IINI,111X11f I'D]
as defined by the Contrail.Municipal Code.Chapter 9.12,and the Health uad Safety HEM ING UNIT(OVER I01,00f1 BTU)
Gids.Section 25532(x)^
/
C]ye, [-I No, VENTILATION FAN(SINGLE RESID) PAID
Date Rereiplp
Will the applicant or future Mui lding Occupant use equipment or devices which ROSLE.R-COMP(3HP OR 100.fFM BTU)
t hnsardim,air cnntaminnn¢as defined by the Bay Area Air Quality Management TOTAL:
r lrlet7 BOII.I➢d-COMP(OVER 1111901X)BTU) _
E]Ye" QNu
AIR CONDITIONER ISSUANCE DATE
1 have read the M1aore.Se materials mry5533 real
under Chapter 0.95.E Ihe ifthe
furca Heald&Safelytly have Sections 25505.'_s my munisi3J.1 Ormdemand mmif the NEW RESIDENTIAL MECII. SQ.PT
building uirenmturcndy have atenant.Ihm o ismyce Of0 ori utrereifycc pancriticpam
of the oquircmenu which must be ma prior to nfuCenificvmof(kcupuncy. -
Owner or lanhuried agent Dune T1931'\ ISSBCD II@
OFFICE